Provider Demographics
NPI:1205035862
Name:ANDERSON, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDLES
Mailing Address - State:CA
Mailing Address - Zip Code:92363
Mailing Address - Country:US
Mailing Address - Phone:760-326-4590
Mailing Address - Fax:760-326-3154
Practice Address - Street 1:640 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-2115
Practice Address - Country:US
Practice Address - Phone:760-326-4590
Practice Address - Fax:760-326-3154
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)